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NTSB Cooperative Boating Accident Investigation

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In 2006, following the Ethan Allen accident, NTSB held a training seminar on NTSB marine accident investigations of sole-state passenger vessel accidents which provided the initiative to revise the ...

In 2006, following the Ethan Allen accident, NTSB held a training seminar on NTSB marine accident investigations of sole-state passenger vessel accidents which provided the initiative to revise the Model Act for charter Vessel Safety. Recreational boating accident investigations jointly worked between a state and NTSB are a much different process and sharing the lessons learned from the April 12, 2009 Jacksonville boating accident jointly investigated by Florida FWC and NTSB will benefit both the NTSB and NASBLA membership in future cooperative investigations and recognition of each others roles and responsibilities in boating safety.

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NTSB Cooperative Boating Accident Investigation Presentation Transcript

  • 1. Cooperative Boating Accident Investigation
    Presented to NASBLA
    September 30, 2009, Corpus Christi, Texas
    By Rob Henry
  • 2. Presentation Overview
    Brief description of NTSB
    NTSB marine accident investigation
    NTSB safety recommendations
    April 12th Jacksonville, Florida boating accident
    Opportunities and challenges
  • 3. 42 Years Ago - 1967-2009
    Created in 1967 by the Congress with the authority to investigate aviation, marine, rail, highway, pipeline, and hazmat transportation accidents.
    In 1974,Congress made the NTSB completely independent of the DOT.
  • 4. Mission of the NTSB
    The NTSB is charged with
    Determining the probable cause(s) of transportation accidents, and
    Making recommendations to prevent their recurrence.
  • 5. The Safety Board Members
    The Safety Board consists of five Members, appointed by the President, with the advice and consent of the Senate. Members serve 5-year staggered terms.
  • 6. Authority to Investigate Marine Accidents
    MayInvestigate Any Major Marine Accident Involving a Foreign Vessel Which Occurs in U. S. Waters
    May Investigate Any Major Marine Accident Involving a U.S. Ship Anywhere in the World
    Shall Investigate Any Collision Between a Public and a Non-Public Vessel
    May Investigate Other Marine Accidents of a Recurring Nature
  • 7. Major Marine Accident Definition
    Six or More Lives Lost
    Total Loss of a Self-Propelled Vessel of 100 Gross Tons or more
    $500,000 or more in Property Damage
    Serious Threat to Life, Property, or the Environment From the Release of Hazardous Materials
  • 8. There Are Many Different Types of Marine Accidents
    The Office of Marine Safety Investigates. . .
  • 9. Collisions
  • 10. Groundings
  • 11. Fires
  • 12. Explosions
  • 13. And Last,
  • 14. But Not Least . . .
  • 15. We Also Investigate
  • 16. Sinkings
  • 17. There are Many Different Types of Vessels Involved in Marine Accidents, Including . . .
  • 18. Foreign Passenger Ships
  • 19. Domestic Passenger Vessels
  • 20. Commercial Fishing Vessels
  • 21. Offshore Service Vessels
  • 22. Offshore Supply
  • 23. Mobil Offshore Drilling Units
  • 24. Tankships
  • 25. Tugboats
  • 26. Towboats
  • 27. Barges
  • 28. Containerships
  • 29. And Last, But Not Least,
  • 30. Recreational Boats
  • 31. Number of Accidents
    In An Average Year, About 6000 Commercial Vessel Accidents Reportable To The Coast Guard
    About 30-40 Of These Accidents Meet At Least One Criteria For Major Marine Accident
    NTSB Investigates Approximately 6-8 Major Marine Accidents Each Year
  • 32. Independent Investigation Under NTSB Rules
    Accident Has Significant Safety Issues
    Accident Has High Loss of Life or Major Pollution
    Accident Has Wide Public Interest, or
    Accident Involves Public Vessel or Major Coast Guard Function
  • 33. Under NTSB Rules
    Launch “GO TEAM”
    On 24-Hour Call
    365 Days A Year
    Enroute In 2 Hours of Notification
  • 34. Typical Go Team
    Investigator-In-Charge
    Marine Engineering Group Chairman
    Human Performance Group Chairman
    Survival Factors Group Chairman
    Other Group Chairmen, As Necessary
    Fire Science
    Metallurgy
    Hazardous Materials
  • 35. Member Launch
    Safety Board Member May Launch With Team, Depending Upon Seriousness
    Typically will include a public affairs officer and a family assistance specialist.
  • 36. Investigation to Report
    On scene investigation usually takes one to two weeks
    Report development will take a year for a complex major marine investigation
  • 37. Board Meeting
    The Board Members conduct a public meeting to discuss and approve a final report on the accident. The final report includes conclusions, a statement of probable cause, and recommendations.
  • 38. Safety Recommendations
    Safety recommendations are the Board’s most important product
    They are developed to remedy system, hardware, operational or policy failures identified during investigations
  • 39. Safety Recommendations
    Recommendations are issued to DOT and its modal administrations, DHS (US Coast Guard), manufacturers, transportation operators, trade associations, labor unions and state and local governments
  • 40. Major Accomplishments
    Improved Fire Protection on Cruise Ships
    Sprinkler Systems
    Smoke Detectors
    Improved Lifesaving Equipment on Commercial Fishing Vessels
    Life rafts
    Survival Suits
    EPIRBs
    Improved Navigation Safety
    Bridge Resource Management Training
    Standardization of Integrated Bridge Navigation Systems
  • 41. “Most Wanted” List
    Safety recommendation issuearea selected by the Board for intensive follow-up because it:
    Will impact or enhance safety on the national level
    Has high public visibility and interest
    Can be implemented in a reasonable period of time; and
    Is an area that would benefit from this special form of encouragement
  • 42. NTSB Safety Initiatives
    1993 Recreational Boating Safety Study
    1998 PWC Safety Study
    2006 public forum on life jackets
    2006 sole state waters seminar
  • 43. Prior NTSB Boating Accidents
    July 3, 1999, Bayport, MN - Advantage & Bayliner - 5 of 5 fatal
    December 29, 1997, Charleston, SC – Morning Dew - 4 of 4 fatal
    August 21, 1994, Juneau, AK – Questar - 1of 2 fatal
  • 44. Allision of the Unnamed Recreational Vessel (Crownline 22) with the towing vessel Little Man II, near Palm Valley, Florida
    April 12, 2009
  • 45. Arial photos
  • 46. Arial photos
  • 47. M/V Little Man II - damage
  • 48. Crownline 22 damage
  • 49. Consequences of Accident
    14 Passengers – none ejected
    5 fatalities
    9 seriously injured
    3 medevaced to local hospitals
    No one walked away from the accident unscathed
    Unique opportunity to conduct a Federal-State Cooperative boating accident investigation
  • 50. Launch
    Early decision between NTSB and USCG on Federal primacy
    Duty Board Member to launch
    Go Team
    Notification of launch to Florida FWC
    Lead investigator contact
    Public affairs contact
    Team arrival Jax and press conference
  • 51. Arrival On Scene
    Set Up Command Post
    IIC Holds Organizational Meeting
    Designates Parties to the Investigation
    Explains Ground Rules
    Forms Investigative Groups
    Groups Disperse to Conduct Investigation
    Progress Meetings Every Evening
  • 52. Party Designation
    Organizations are Named as Parties Because they Have Special Knowledge or Resources that the Board Needs to Complete the Investigation.
    Party Representatives Can Not Be Lawyers or Insurers & Must Have Technical Qualifications
  • 53. Parties to investigation
    Florida FWC
    Region supervisor
    5 investigators, 1 PAO
    U.S. Coast Guard
    Senior investigating officer (LT)
    Inspections division chief (LT)
  • 54. Causal Issues – proximate cause
    Human factors
    Deceased sitting “operator”
    Lacked training and experience, inattention, view obstructions, line of sight, distractions
    Surviving standing “operator”
    Intoxication, inattention, distractions
    Owner of record
    Responsibility for oversight of vessel operation, intoxication
  • 55.
  • 56. NTSB Authority
    Issues Subpoenas
    Take Testimony Under Oath
    May Enter Any Property Where Accident Has Occurred
    Copy Pertinent Files and Documents
    Order Autopsy of Accident Victims
    Test any component of the wreckage
  • 57. NTSB Resources
    Materials laboratory
    Transportation disaster assistance/ family assistance
    Medical evaluation of autopsies and tox tests. MD on staff
    Commercial vessel A/I experience
    Weather data retrieval and analysis
    Data recorder recovery and analysis
    Human factors specialist
    Tox laboratory
  • 58. State Capability and Resources
    Accident reconstruction and documentation expertise
    Local knowledge
    Site security
    Logistical support
  • 59. Challenges to Cooperation
    Early communications and coordination
    Non-criminal process
    Lawyers/due process
    Overlapping investigation needs
    Interviews
    Data and evidence collection
    Access to accident site
    Limited opportunity to investigate recreational boating accidents
  • 60. Challenges
    Public dissemination of information
    Conflicting A/I protocols
    Safety vs. law enforcement
    Rights of interviewees
    Warnings
    Immunity
    Self-incrimination
    Representation
    Collection of evidence (rules of, chain of custody)
    Transparency of NTSB investigation
  • 61. Conclusion
    Why is mutual cooperation important to each of us?
  • 62.
  • 63. Judicial Process and NTSB
    Board employees may testify once (through deposition or interrogatories) for all civil litigations (49 CFR § 835.5)
    NTSB makes available unique factual information not otherwise available
    NTSB Board Reports may not be used or admitted into evidence in any action for damages arising from an accident (49 CFR § 835.3)
    Interaction with United States Attorneys is rare and limited
    General Counsel determines if staff may testify in criminal matter (49 CFR § 835.10)
  • 64. NTSB and the Coast Guard
    • Joint Regulations (49 CFR Part 850)
    • 65. NTSB – USCG Memorandum of Understanding, signed December 19, 2008
    • 66. Coast Guard a party to NTSB-led investigations
    NTSB
  • 67. NTSB Has Three Options:
    • Request the Coast Guard to Investigate On Behalf of the Safety Board With No NTSB Participation, or
    • 68. Conduct a Joint Investigation With the Coast Guard Under Coast Guard Rules, or
    • 69. Conduct an Independent Investigation Under NTSB Rule.
  • Investigating Marine Accidents
    Entire Marine Investigative Staff Works Out of Washington, D.C. Headquarters
    Current Marine Technical Staff - Persons
    Master Mariners
    Licensed Marine Engineers
    Naval Architects
    Human Performance
    Survival Factors